Provider Demographics
NPI:1710579578
Name:PARKER, KEANNA ALEXANDRIA
Entity Type:Individual
Prefix:
First Name:KEANNA
Middle Name:ALEXANDRIA
Last Name:PARKER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:133 N ARBOR TRL APT 409
Mailing Address - Street 2:
Mailing Address - City:PARK FOREST
Mailing Address - State:IL
Mailing Address - Zip Code:60466-2679
Mailing Address - Country:US
Mailing Address - Phone:708-674-6501
Mailing Address - Fax:
Practice Address - Street 1:133 N ARBOR TRL APT 409
Practice Address - Street 2:
Practice Address - City:PARK FOREST
Practice Address - State:IL
Practice Address - Zip Code:60466-2679
Practice Address - Country:US
Practice Address - Phone:708-674-6501
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-02-03
Last Update Date:2021-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL041.478615163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse